| Patient identification, referral, treatment and follow up |
Poor pregnancy surveillance, recording and poor linkage between antenatal care and the health post and health centre/hospital |
A format on pregnancy cohort (listing pregnant mothers whose expected date of delivery was in the same month separately) was designed and distributed to each of the health centres. On-site training was provided to HEWs on the use of the format by the TSU. Health centres linked the pregnant women who visited the health centre for their first antenatal care follow-up with the HEWs. Laboratory results of pregnant women were communicated through a formal referral slip to the HEWs from the health posts. |
| Poor postnatal care home visit services |
Consultations and discussions were held between the HEWs and the TSU to ensure adherence to the postnatal care guideline of the FMoH (home visits on days 1, 3, 7 and 42). Sustainability remains a challenge. |
| Failure of HEWs to carry out CBNC activities properly |
Refresher training was provided to HEWs by master trainers and Save the Children with support from the TSU. This was complemented with on-site training by the TSU, the clinical mentors and the supervisors during the first two quarters which resulted in improvement in the skills to carry out activities as per standard case management. |
| Mismatch between assessment and classification as per chart booklet (not using the chart booklet) |
On-site training was provided to HEWs by the TSU on the use of the job aids distributed to health posts during the first quarter, with subsequent on-site mentorship by the TSU through the second and third quarters. This resulted in improvement in the skills to carry out activities as per standard case management in the subsequent quarters. |
| Poor on-site supportive supervision from the district health office and cluster supervisors |
Consultations, review meetings and discussions were held with the RHB, district health office and health centre staff and HEWs. Training was provided to the district supervisors and health centre staff by the TSU. Subsequently agreements were reached between the TSU, health centres and the District Health Offices to increase the frequency of supportive supervisory visits to health posts from once in six months to at least quarterly by the district health office and monthly by the TSU. |
| Confusion in the definition of young infant as a neonate (first 28 days of life) |
Refresher and onsite training were provided to HEWs, health centre and district health staff by the TSU to resolve confusion. |
| Confusion between integrated community case management (iCCM) and CBNC during the early days of project implementation |
HEWs, health workers from health centres and experts from the districts had a better awareness of iCCM than CBNC as iCCM had been in place for a few years. Refresher and on-site training were provided by Save the Children and the TSU. |
| Poor referral linkage across all levels |
Consultations and discussions were held between the TSU, FMoH, RHB and the district health office to improve the referral and feedback linkages and communication between health workers at different levels. They agreed to have an auditable referral system and to review the referrals during their meetings. |
| Discrepancies between the management of PSBI at health posts and health centres and ill-equipped health centres to manage referred PSBI cases |
Refresher and on-site training during the supportive supervisory visits were provided to health post and health centre staff in the study area. In addition, consultations and discussions were made with the RHB to address discrepancies. As a result, the RHB wrote a letter to the health centres to comply with using the simplified antibiotic treatment regimen implemented by the health posts unless the health centre has the capacity to admit and manage cases on an inpatient basis. The health centre workers were trained on PSBI case management by the TSU during the third quarter. |
| Poor health care-seeking behaviour of mothers |
Refresher training was provided to the HEWs and WDGs to create demand for the services provided at the health post. Community mobilization activities to increase care-seeking were also undertaken. |
| Referral and treatment |
Tendency of the HEWs to treat rather than to refer sick young infants with PSBI during the initial period of implementation research |
Refresher training and on-site supportive supervisory visits were provided to the HEWs to counsel mothers or families of sick young infants for referral to the next higher level of care. HEWs were made to understand to only treat sick young infants whose families refused to accept referral. |
| Expiry of medicines for simplified treatment regimen of PSBI |
During the on-site supportive supervisory visits of the TSU, the HEWs from the health posts were trained on how to read the expiry dates of drugs, report the drugs with short shelf lives and redistribute them to nearby health posts. Templates were developed for redistribution and reporting of these drugs in consultation with district health offices. |
| Data Collection |
The health management information system format was not capturing data on PSBI |
TSU held discussions with the RHB and the FMoH to align the information in the health management information system and CBNC, which resulted in a few key indicators to be incorporated in the revised DHIS. |
| Complicated data collection instruments (CRFs) has challenged their completion |
During the initial period of project implementation, the HEWs were concerned about the number and complexity of the data collection tools and did not complete some of the forms. Additional onsite training was provided to the HEWs to complete the various CRFs. TSU also revised the tools to make them much simpler. |
| Administrative issues |
Heavy workload of HEWs and missing of scheduled visits |
Consultations and discussions were made with the RHB to increase the number of HEWs. The RHB agreed in principle, but the number did not increase in many places. Health centre staff provided support to health posts when HEWs were unavailable, which this has worked well. |
| Disconnect between the health posts and the district health office and health centres regarding the implementation of the CBNC programme |
Consultations and discussions were held between the TSU and the district health office and health centres on CBNC and health post-based management of PSBI during the end of the first quarter, and quarterly review meetings chaired by the head of the RHB were held to improve the buy-in and ownership of the CBNC by the district health office and health centres. The district health office supervisors were included in the monitoring and evaluation activities of the TSU starting in the second quarter. |
| Closure of health posts during working hours, especially during campaigns |
Discussions were held with the district health offices and the HEWs in order to have one HEW at the health post during working hours. Additionally, it was agreed that the health posts would remain open during working hours even during public health campaigns. The district health office committed to send health workers from health centres when both the HEWs were unavailable at the health post. |
